Treatments and Theraphy of Coronary Heart Disease

The goal of treatment are:
a. Improve prognosis by preventing myocardial infarction and death. Efforts is how to reduce the occurrence of acute thrombotic and left ventricular dysfunction. This goal can be achieved by lifestyle modification or pharmacologic interventions that will:

(i) subtracting the progressive plaque

(ii) stabilize the plaque, by reducing inflammation and improving endothelial function, and finally

(iii) to prevent thrombosis or endothelial dysfunction in the event of plaque rupture.

Drugs used: antithrombotic drugs: a low-dose aspirin, ADP receptor antagonists (thienopyridin) that clopidogrel and ticlopidine; cholesterol-lowering drugs (statins), ACE-Inhibitors: Beta-blockers: Calcium channel blockers (CCBs).

b. To cope with symptoms and ischemia: the drug used. Nitric working short and long term, beta-blockers, CCBs.

General Procedures

       To patients suffering from CHD and their families, need to be briefed about the course of the disease and the choice of drugs available. Patients should be reassured that most cases of angina can be improved with medication and lifestyle modifications so that the quality of life better. Comorbid disorders such as hypertension, diabetes, dyslipidemia, etc..

CHD treatments, consisting of pharmacological treatment and myocardial revascularization. Keep in mind that none of the above nature cure. In other words it is necessary lifestyle modifications and addressing the causes that disease progression can be slowed.

Pharmacologic treatment

* Low-dose aspirin

From various studies have clearly shown that aspirin is still the main drug for the prevention of thrombosis. Meta-analysis showed that a dose of 75-150 mg equal effectiveness compared with larger doses. Therefore, aspirin is recommended in all patients with CHD were given unless contraindicated encountered. In addition to aspirin is also recommended that given the long-term side effects but it should be noted gastrointestinal irritation and bleeding, and allergies. Cardioaspirin provide a more minimal side effects other than aspirin.

* Inhibits platelet aggregation

Thienopyridine Clopidogrel and ticlopidine are antagonists of ADP and inhibits platelet aggregation. Clopidogrel is more indicated in patients with resistance or intolerance to aspirin.

AHA / ACC guidelines update the 2006 include a combination of aspirin and clopidogrel should be given to patients with PCI with stent implantation, over 1 month for bare metal stent, 3 months for sirolimus eluting stent and 6 months for paclitaxel-eluting stent.

* Cholesterol-lowering drugs

Treatment with statin use to reduce risk in both primary prevention and secondary prevention. Various studies have shown that statins can reduce complications by 39% (Heart Protection Study), Ascott-LLA atorvastatin for primary prevention of CHD in post-hypertension.

Than as a cholesterol-lowering statins, also have other mechanisms (pleiotropic effect) which can act as an anti-inflammatory, anti-thrombotic etc.. Provision of atorvastatin 40 mg one week prior to PCI may reduce myocardial damage due to the action. Target reduction in LDL cholesterol is <100 mg / dl and in high risk patients, DM, CHD patients is recommended lowering LDL cholesterol <70 mg / dl.

* ACE-Inhibitor/ARB
The role of ACE-I as secondary prevention for Cardioprotection in patients with CHD has been demonstrated from various studies, among others., HOPE study, etc. EUROPA study. If intolerance to ACE-I may be replaced by the ARB.
* Nitrate is generally recommended, because nitrate has an effect so venodilator myocardial preload and left ventricular end volume and thus decreases myocardial oxygen consumption also decreases. Nitrates also dilate blood vessels of normal and atherosclerotic experiencing. Raise collateral blood flow, and inhibits platelet aggregation. When an attack of angina does not respond to short-term nitrate, then be wary of myocardial infarction. Drug side effects are headaches, and flushing.
* Beta blockers 

Beta Blockers are also a standard drug. Beta blockers block the effects of catecholamines on the circulation and Beta-1 receptors which can cause a decrease in myocardial oxygen consumption. Beta blockers do with the provision of a target heart rate 50-60 per minute. The most important  contraindication to beta blocker administration is history of bronchial asthma, and acute left ventricular dysfunction.
* Calcium antagonists 

 have the effect of vasodilatation. Calcium antagonists can reduce complaints in patients who had received nitrates or beta blockers; but it is also useful in patients whoose contraindications to the use of Beta blockers. Calcium antagonists is not recommended if there is a decrease in left ventricular function or conduction disturbances atrioventricular. 

Treatment recommendations to improve the prognosis of patients with unstable angina according to the ESC 2006 as follows.:
1. Giving aspirin 75 mg per day in all patients without specific contraindications (ex. active gastric bleeding, aspirin allergy, or a history of aspirin intolerance) (level of evidence A).
2. Statin treatment for all patients with coronary heart disease (evidence level A).
3. The provision of ACE inhibitors in patients with an indication of the provision of ACE inhibitors, such as hypertension, left ventricular dysfunction, history of myocardial infarction with left ventricular dysfunction, or diabetes (level of evidence A).
4. Provision of oral beta-blockers in patients with heart failure or myocardial infarction who had received (evidence level A).

Myocardial revascularization
      There are two ways that have proven good revascularization in stable CHD is caused by atherosclerotic coronary revascularization act of surgery, coronary bypass surgery (coronary artery bypass surgery = CABG) and percutaneous intervention (PCI = percutneous coronary intervention).
Lately, both methods have progressed rapidly in the introduction of action, off pump with minimally invasive surgery and drug eluting stent (DES). Revascularization goal is to improve survival or prevent infarction or for relief of symptoms. Where the action is chosen, depending on the risk and patient complaints.
Indications for Revascularization
In general, patients who have indications for coronary arteriography and actions performed catheterization showed narrowing of the coronary arteries is a potential candidate for myocardial revascularization action. In addition, the act of revascularization performed on the patient, if:
a. Treatment failed to control the patient's complaints.
b. Non-invasive test results indicate a risk of infarction.
c. Found a high risk for the incidence and mortality.
d. Patients prefer the intervention compared with usual treatment and fully understand the risks of the treatment given to them.


Actions CABG Surgery
Surgery is better to do than with medication, in the circumstances:
a. Significant stenosis (≥ 50%) in the left main (LM).
b. Significant stenosis (≥ 70%) in the region proximal to the 3 major coronary arteries.
c. Significant stenosis in two main areas, including coronary artery stenosis is high enough levels in the proximal region of the left anterior descending coronary artery.


PCI acts
        In the first act of percutaneous transluminal angioplasty is only performed on the blood vessels only, now it has grown more rapidly both because of the experience, equipment, especially stents and drug investigations. In patients with stable CHD with appropriate coronary anatomy of the PCI can be performed on one or more blood vessels (multi-vessel) with a good (successful PCI). The risk of death by about 0.3-1% of this action. Action PCI in patients with stable CHD compared with medical drugs, not add to survival and it is different than CABG.


Installation of Elective Stent and Drug-eluting stents (DES)
      Stenting can reduce restenosis and repeat PCI compared with balloon angioplasty actions. Currently available drug-coated stent (drug-eluting stent = DES) as serolimus, paclitaxel, etc.. Compared with bare-metal stents, the use of DES may reduce restenosis. RAVEL study showed restenosis can be reduced to 0%. Direct stenting (stent without balloon pre-dilatation with the first) is a feasible action in patients with coronary artery stenosis without calcification is a specific, single lesion, without angulation or severe turtoasitas. Direct action stenting can reduce the time the action / ischemic time, reduce radiation, the use of contrast, to reduce costs.


Primary Percutaneous Coronary Intervention actions (Primary PCI)
        Stable CHD patients had complications and had a heart attack (ACS), mortality is very high (> 90%). With advances in technology have now been able to do primary percutaneous coronary intervention (primary PCI) is a technique to remove thrombi and dilate the narrowed coronary arteries with balloon catheters and stent insertion is often done. This action can remove the blockage immediately, so that blood flow can be normal again, so the heart muscle damage can be avoided. Primary PCI is the treatment of acute cardiac infarction are best at this, because it can stop the attack of acute cardiac infarction and reduce mortality to below 2%.